Provider Demographics
NPI:1376605998
Name:WHITLEY, JIMMIE C (EDD)
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:C
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 CYPRESS STATION DR
Mailing Address - Street 2:BUILDING B-1
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3054
Mailing Address - Country:US
Mailing Address - Phone:281-537-7207
Mailing Address - Fax:281-580-5061
Practice Address - Street 1:1125 CYPRESS STATION DR
Practice Address - Street 2:BUILDING B-1
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3054
Practice Address - Country:US
Practice Address - Phone:281-537-7207
Practice Address - Fax:281-580-5061
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX2-1974103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115635801Medicaid